liabilities are the second biggest debt across all Government departments after
nuclear decommissioning. This startling fact was shared with delegates at
APIL’s annual clinical negligence conference earlier this week by a Department
of Health civil servant.
was one of horror. How on earth has the NHS and the NHSLA allowed things to get
so out of hand? Who, in the Department of Health’s hierarchy, thought that it
was good practice to allow the NHS to be so negligent, so often, that its
liabilities just ran away from any form of control?
It’s all very
well for the DoH and NHSLA to talk about the NHS’s need to be a learning
organisation and to support changes to prevent harm in the first place, but
some concrete action is urgently needed.
Why is it
that time after time, experienced lawyers point to the repeated mistakes made
by the NHS and nothing seems to change?
How can it be right that the NHS is still causing brain damage, as a
result of negligent maternal and obstetric care, to the same number of babies
as it damaged in 2006? In the 2015-16
financial year, 42 per cent – over a billion pounds – of the compensation paid
out by the NHSLA related to obstetric claims, paid mainly to brain damaged
cases, lawyers and their clients are the whistle-blowers - alerting the NHS to
its failings and asking for assurances that the same thing will never happen
again to another patient. Time and time again, the NHS fails to react, denies
that it was negligent until the last minute and does not seem to learn.
At the APIL
conference last week the same civil servant talked about ‘black box thinking’ -
a reference to the book with that title, by Matthew Syed. In the book he
compares the aviation industry’s commitment to safety to that in the NHS. Every
air accident is examined, the reasons for it are extracted and procedures
changed, so that the same error never happens again. As a result, “for every
one million flights on western-built jets there were 0.41 accidents – a rate of
one accident per 2.4 million flights.” Now compare that with the NHS. A National
Audit office report
said that “that there was no systematic pattern as to how trusts determined
what incidents required a detailed investigation” and that at one trust, “they
assess the ‘ooo-er factor’ of an incident – that is, whether an incident is
serious, potentially serious or unusual and therefore may warrant further
indeed. That same report indicated the NHS does not really know how many deaths
results from patient safety incidents. It estimated that there may be between
2,181 and 34,000 deaths a year – but no-one knows, because no-one is collecting
the right data. If the lower end is correct (and that is unlikely as it is from
a survey of Trusts to which not all of them responded) that’s 5.9 preventable
premature deaths a day. If the higher number is correct, that’s five 747 jets
falling out of the sky every month. Imagine if any other
industry was allowed to continue to kill and injure its customers and get away
with it on a similar scale: there would be an international outcry. It is intolerable that the NHS is allowed to
continue to operate with this degree of death and injury and high time it took
urgent action to change.